_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
2007- 2008 State Instructional Materials
Committee Member Nomination Form
Part I – Completed by the Nominating Individual, Agency, or Association.
Please provide the following information regarding the nominee. PART II is to be completed by the nominee. Both PARTS I and
II are to be submitted to Patty Ceci, Office of Instructional Materials, Florida Department of Education, 325 West Gaines, Suite
424, Tallahassee, FL 32399-0400.
(Please print)
1. Name of nominee: ________________________________________________________________________________________
2. School district of nominee:___________________________________________________________________________________
3. In what capacity do you know the nominee? ____________________________________________________________________
4.
?
State Instructional Materials Committee for which nomination is being submitted:
____ Reading Education K-5
____Reading Education 6-12
5. Please check the category for which this nomination is being submitted:
_______ Teacher/Literacy Coach
Lay Citizen/Community Member/Parent
_______ Supervisor/Curriculum Supervisor
School Board Member
6. Name of agency, association, institution, organization or individual making the nomination:
(Individual)
(Title)
?
(Association/Institution/Organization)
7. Address of agency, association, institution, organization or individual making the nomination:
________________________________
(City)
(State) (Zip) (Telephone
Number)
8. E-mail: __________________________________________________
I hereby certify that all statements made in this questionnaire are to the best of my knowledge true and correct.
__________________________________________________ __________________________________________________
(Nominator’s Signature)
?
(Date)
1
___________________________________________________________________________________________________________
2007- 2008 State Instructional Materials
Committee Member Nomination Form
Part II - Completed by the Nominee.
Return to Patty Ceci, Office of Instructional Materials, Florida Department of Education, 325 West Gaines, Suite 424,
Tallahassee, FL 32399-0400.
(Please Print)
1. Full Name: ____________________________________________________________Preferred Name________________________
2. Address: _________________________________________________________________________________________________
_________________________________________________________________________________________________
(City)
(County)
(State) (Zip)
3.
?
Telephone:
(Home)
(Business)
4. E-Mail Address:_________________________________ Alternate E-mail Address:______________________________________
5. Are you a resident of the State of Florida? Yes
?
No________
6. School District: ___________________________School Name (If applicable):__________________________________________
7. Category for which this nomination is being submitted:
_______ Teacher/Literacy Coach
______ Lay Citizen/Community Member/Parent
?
_______ Supervisor/Curriculum Supervisor ______ School Board Member
?
8.
?
State Instructional Materials Committee for which nomination is being submitted:
____ Reading Education K-5
____ Reading Education 6-12
Although not required, preference will be given to nominees with an Exceptional Student Education (ESE) background
and/or expertise in technology. Please check if you have this experience.
____ K -5 ESE background
_____ Technology Expertise
?
____ 6 -12 ESE background
?
9. Occupation:
10. Job Title:
11. Name and address of present employer:
12. Educational background:
2
____________________________________________________________________________________________________________
13. Experience (where applicable, you may also submit your vita or resume):
(a) Teaching:
(b) Reading Instruction:
(c) ESE: ____________________________________________________________________________________________________
(d) Technology: ______________________________________________________________________________________________
(e) Administrative:
(f) Other Employment:
14.
Public service: (List any public office you now hold or have held and/or any employment by a government agency or service on
federal, state and/or local advisory committees, commissions, councils or task forces.)
15.
Affiliations: (List national, state, community and/or educational organizations in which you are now or have been a member.)
16.
If you are presently a classroom teacher/coach or teacher/curriculum supervisor, please list below the subjects you are
teaching/supervising and the grade level(s) at which the instruction/supervision is provided:
SUBJECT AREA(S)
GRADE LEVEL(S)
17. Do you now hold or have you ever held a teaching certificate in the State of Florida or any other state?
?
Yes _____ No _____
?
Currently valid? Yes _____ No _____ Subject Area(s) and Grade Level(s):________________________________________________
?
Has your certificate ever been suspended or revoked in this or any other state? Yes _____ No _____
?
If yes, when?
Where?_____________________________________
?
18. Have you been designated “Teacher of the Year” at any level? Yes____ No_____
?
If yes, please provide the following information: Award Level (School, District, Regional, State or National) and Award Year.
?
19. Do you hold National Board Certification? Yes _____ No _____
?
If yes, please provide year certified and certification area: __________________________________________________________
?
3
_________________________________________
_________________________________________
_________________________________________
_________________________________________
20. Have you ever been convicted of a felony or first degree misdemeanor? Yes _____ No _____
?
If yes, what charge(s)?
?
Where?
When?
?
21. Have you previously served on a state instructional materials committee?
_____ Yes _____ No
When?
Subject? _____________________________
Have you previously served on a district instructional materials committee? _____ Yes _____ No
When?
Subject? _____________________________
22. Briefly state why you are interested in serving on this committee:
I hereby certify that all statements made in this questionnaire are to the best of my knowledge true and correct.
(Nominee’s Signature)
(Supervisor’s Signature)
(Date)
(Date)
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
The information requested below is needed to satisfy Equal Employment Opportunity reporting and research
requirements.
__ __ __ __ __ __ __ __ __
_Female
_Male
Social Security Number
Check the race/ethnic group with which you identify:
_White _African American _Hispanic _Asian or Pacific Islander _American Indian or Alaskan Native
4
?